The Surgical Approach to the

Acute Abdomen
Andi Djaja Pratama

The acute abdomen refers to the clinical

situation in which an acute change in the
condition of the intraabdominal organs,
usually related to inflammation or
infection, demands immediate and
accurate diagnosis.

The term acute abdomen should never be

equated with the invariable need for
operation.

Zachary Cope, MD, 1927

The Acute Abdomen

Abdominal pain is one of the most frequent
reasons to visit physician offices and emergency
rooms
Most patients are found to have self limited
conditions
A subset of patients harbor serious intraabdominal
disease that requires urgent surgical or medical
intervention

The Acute Abdomen

Early diagnosis is the key to improving outcomes
An accurate history and complete physical
examination are more important than any
diagnostic test
The history should be obtained with the abdomen
bare, with attention to how the patient positions
himself and moves

The Acute Abdomen

Early evaluation by experienced physicians is
important, as once the initial evaluation is done
analgesia may be given
Antibiotics should not be given until a working
diagnosis is made
Serial examinations by the same physician during
the patients work up determines disease
progression or resolution

Peritoneal Signs
Palpation and Percussion BE GENTLE
Rebound please do not perform this test
Causes unexpected and unnecessary pain
Does not add information to an examination
after percussion

Rigidity
not present in pelvic inflammation or
obstruction

The Acute Abdomen

Review anatomy and physiology of
abdominal pain
Review some common causes of the acute
abdomen

Abdominal Pain
Acute abdominal pain is the hallmark of an
acute abdomen
It may originate from any organ in the
abdominal cavity
Understanding the mechanisms of pain
production and the physiology of pain
perception allow for more accurate
diagnoses

Abdominal Pain
Pain may be visceral, somatic or referred
Visceral pain is characterized by dullness,
poor localization, cramping, burning or
gnawing
Visceral pain is mediated by autonomic
(sympathetic and parasympathetic) nerves
The location of the pain corresponds to the
dermatomes of the organs involved

Abdominal Pain
Sensory neuroreceptors for visceral pain are
located in the mucosa or muscularis of hollow
viscera, on the visceral peritoneum and within the
mesentery
These receptors respond to mechanical and
chemical stimuli
Stretch is the primary mechanical signal for pain

Abdominal Pain
The parietal peritoneum has an entirely somatic
innervation
Somatic pain is more intense and well localized
Somatic innervation is mediated by the spinal
nerves
A transition from visceral to somatic pain
indicates extension of the underlying process

Abdominal Pain
Referred pain is perceived as pain distant from the
involved organ
It is due to a convergence of visceral afferent
neurons with somatic afferent neurons from
different anatomic regions
Referred pain is well localized

Common Causes

Appendicitis
Cholecystitis
Pancreatitis
Diverticulitis
Perforated Ulcer

IBD
Obstruction
Vascular Emergencies
Gynecologic Diseases
Urinary Tract Disease

Appendicitis

Appendicitis
1 in 15 people will develop appendicitis in
their lifetime
Its the most common cause of the acute
abdomen
Peak incidence is from 10 30 years

Appendicitis
History may be classic if youre lucky
Vague peri-umbilical pain is the most
common symptom
McBurneys Point
Hyperesthesia of the abdominal wall
Rovsings, psoas and obturator signs

Appendicitis
Retrocecal appendix occurs 64% of the time
Ultrasound or CT Scan may be used
CT Scan with triple contrast and 5mm cuts
through the level of the appendix is 98%
sensitive for appendicitis
A retrocecal or pelvic appendix or abscess
will NOT cause peritoneal signs

Appendicitis in Pregnancy
Appendicitis is the most common extrauterine
surgical emergency
1 in 6000 pregnancies
Signs and symptoms are unreliable
Derangements in GI physiology include decreased
gastric acid secretion, increased reflux, delayed
gastric emptying and decreased peristalsis
CT scans in the third trimester are safe

Appendicitis in Pregnancy

Acute Cholecystitis

Acute Cholecystitis
Biliary colic is the most common symptom
Pain may radiate to the right shoulder or scapula
The pain is colicky and is associated with nausea
and vomiting
Murphys sign/acute abdomen
Ultrasound

Acute Cholecystitis

Acute Pancreatitis

Acute Pancreatitis
Onset is acute
Abdomen is tender, but rarely has true peritoneal
signs
Grey Turners sign, Cullens sign and Foxs sign
are infrequently seen
Serum amylase and lipase are the biochemical
hallmarks
Ransons criteria is used to torture surgical
housestaff APACHE Score

Acute Pancreatitis
Chest x-rays may show segmental atelectasis,
pleural effusions and an elevated left
hemidiaphragm
KUB may show the sentinel loop and loss of the
psoas shadow
CT scan with double contrast will show pancreatic
edema, retroperitoneal inflammation, and areas of
pancreatic necrosis

Perforated Ulcer

Perforated Ulcer
Perforated ulcer requires immediate operative
therapy
Anterior gastric perforations cause peritonitis
Posterior gastric and duodenal perforations may
not cause peritonitis, and after the acute episode of
pain, the leak may wall off, giving the impression
that the patient is improving
Tympany over the liver at the mid-axillary line is
almost always a perforated ulcer

Perforated Ulcer
Free air (80% of perforated ulcers)
Go to OR

No free air, no peritonitis

Go to CT scan
Subhepatic fluid collection

Diverticulitis

Diverticulitis
Patients may have antecedent history of thinning
bowel movements
Patients may know they have pockets
All colonic pain is hypogastric so bandlike pain
across the lower abdomen is common
Differential includes perforated colon cancer
No endoscopy or contrast enemas in the acute
phase CT Scan

Diverticulitis
CT Scan Diagnostic criteria
Mild: Localized wall thickening (>5 mm),
pericolic fat inflammation
Severe: abscess, extraluminal gas/contrast
Effectiveness
Sensitivity: 93-97%
Cho 1990, Ambrosetti 1997

Diverticulitis

Diverticulitis

Diverticulitis
Patients with peri-diverticular pain and no peritoneal
signs may be managed as outpatients
Patients with localized peritonitis and no abscess
may be given a trial of IV Abx
Abscesses should be percutaneously drained transabdominally
Generalized peritonitis is rare (2-24%), but requires
laparotomy
Gordon 1999

Inflammatory Bowel Disease

Inflammatory Bowel Disease

Crohns Disease
Acute exacerbation in patients with
undiagnosed ileocolic Crohns may be confused
with appendicitis
Laparoscopy may help determine the diagnosis
Isolated Crohns colitis accounts for 25% of all
Crohns disease

Crohns Disease
Operative Indications
Colitis refractory to
medical therapy is the
most common cause for
urgent operation
Persistent hemorrhage and
free perforation are rare

Ulcerative Colitis
Disease Course
Proctitis:
50% pan-colitis; 12% colectomy

Left-sided colitis:
9% pan-colitis; 23% colectomy

Pan-colitis:
40% colectomy
Langholz 1996

Ulcerative Colitis
Disease Severity
Mild colitis: 20%
Moderate colitis: 71%
Severe colitis: 9%

Acute disease complications

Toxic colitis or megacolon
Perforation
Hemorrhage
Langholz 1991

Toxic Colitis
Subjective appearance
Objective criteria:
Fever
Tachycardia
Leukocytosis
Hypoalbuminemia
Colonic diameter greater than 6cm on KUB
Toxic colitis may progress to toxic megacolon

Obstruction

Small Bowel Obstruction

History
Prior surgery
Hernias

Signs and Symptoms

Colicky abdominal pain

Nausea and vomiting
Abdominal distension
Rectal exam

No peritoneal signs

Small Bowel Obstruction

Diagnosis
KUB and upright abdominal films
3cm is upper limit of small bowel diameter

Partial SBO
Colonic gas
Small bowel series if needed

Complete bowel obstruction

Immediate laparotomy

Large Bowel Obstruction

Large Bowel Obstruction

Greater than 50% are malignant
Colorectal cancer is usually the primary
Volvulus and intussuception are other causes

Signs and Symptoms

Gradual onset
Pain is not colicky
Vomiting is rare

Patients with competent ileocecal valves are at

highest risk of perforation

Large Bowel Obstruction

Diagnostic x-rays
Obstruction vs ileus

Rectal exam and rigid proctoscopy

Rigid proctoscopy will detorse sigmoid volvulus

Gastrograffin enema
Cecal volvulus requires laparotomy